Supplemental Health Questionnaire and Informed Consent in Midland, TX

Thank you for your continued trust in our practice. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Therefore, prior to EACH appointment, we will be asking these additional health questions:

Have you had contact with anyone who has confirmed or under investigation for the COVID-19 virus?*

Yes
No

Fever (100F) or history of fever within the last 14 days?*

Yes
No

Sore throat?*

Yes
No

Cough?*

Yes
No

Runny nose?*

Yes
No

Shortness of breath?*

Yes
No

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the novel coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?*

Yes
No

Patient Name*

First Last

Date*

Signature*